Importance: Individuals in the United States with mental illnesses and substance use disorders can face major access barriers from limited provider (eg, clinicians and facilities) networks in health insurance plans.
Objective: To evaluate the cost-sharing payments for out-of-network (OON) care for private insurance plan enrollees with mental health conditions, alcohol use disorders, or drug use disorders compared with those with congestive heart failure (CHF) or diabetes.
Design, setting, and participants: This cross-sectional study used data from a large commercial claims database from 2012 to 2017. The study included adults with mental health conditions, with alcohol use disorders, with drug use disorders, with CHF, and with diabetes who were aged 18 to 64 years and enrolled in employer-sponsored insurance plans.
Main outcomes and measures: Main outcomes included OON care during hospitalization, OON care during outpatient care, cost-sharing payments with OON care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing.
Results: The study sample included 3 209 929 enrollees with mental health conditions (mean [SD] age, 45.9 [12.6] years; 64.8% women), 294 550 with alcohol use disorders (mean [SD] age, 42.8 [13.4] years; 60.9% men), 321 535 with drug use disorders (mean [SD] age, 41.1 [13.9] years; 59.1% men), 178 701 with CHF (mean [SD] age, 53.8 [8.9] years; 62.6% men), and 1 383 398 with diabetes (mean [SD] age, 52.5 [9.0] years; 58.9% men). Enrollees with behavioral conditions were more likely to encounter OON clinicians in inpatient and outpatient settings. For instance, those with drug use disorders were 12.9 percentage points (95% CI, 12.5-13.2 percentage points; P < .001) more likely to have inpatient OON care than those with CHF and 15.3 percentage points (95% CI, 15.1-15.6 percentage points; P < .001) more likely to receive outpatient OON care. Behavioral conditions also had higher cost sharing for OON care. For example, individuals with mental health conditions had cost-sharing payments for OON care $341 (95% CI, $331-$351) higher than those with diabetes (P < .001), individuals with drug use disorders had cost-sharing payments for OON care $1242 (95% CI, $1209-$1276) higher than those with diabetes (P < .001), and individuals with alcohol use disorders had cost-sharing payments for OON care $1138 (95% CI, $1101-$1174) higher than those with diabetes (P < .001). The OON care rates and cost-sharing payments were much higher when enrollees sought care from behavioral clinicians and facilities.
Conclusions and relevance: In this cross-sectional study of enrollees in commercial insurance plans, cost sharing for OON care among those with behavioral health conditions was significantly higher than those with chronic physical conditions. These disparities may be indicative of limited in-network availability for behavioral health care.